Results.Nurse
prescribers and physicians correctly documented 96.0% and 94.9% of the
time, respectively. There was a trend towards a higher proportion of
social history documentation by the nurses, but no significant
difference in any other documentation items.

Conclusions.Our
findings support the continued investment in programmes employing
properly trained nurses in southern Africa to provide quality care and
ART services to HIV-infected children who are stable on therapy. Task
shifting remains a promising strategy to scale up and sustain adult and
paediatric ART more effectively, particularly where provider shortages
threaten ART rollout. Policies guiding ART services in southern Africa
should avoid restricting the delivery of crucial services to doctors,
especially where their numbers are limited.

S Afr Med J 2012;102:34-37.

In areas where HIV prevalence is high and resources are limited,
models of care that rely exclusively on doctors to provide patient
management are not always feasible. Doctor shortages are expected to
continue worsening in high-prevalence settings in coming years, further
exacerbating these difficulties.1,2
This is particularly true where the availability of paediatric HIV care
is concerned, as global shortages of doctors with paediatric experience
are well documented,3 and nearly 7 of every 10 children who need antiretroviral therapy (ART) do not currently receive it.6
A distinct challenge to the global goal of universal access to ART is
therefore the under-representation of children, as opposed to adults,
in ART programmes.6,7

Programmes are therefore increasingly turning to task-shifting
strategies to address human resource limitations and to facilitate both
decentralisation and scale-up of health care services.8 The
African experience with task-shifting of HIV care and treatment by
non-doctor clinicians has so far increased the number of patients on
ART and improved the decentralisation of services.9 While there are legitimate concerns about the quality of task-shifted care,13,15 good outcomes have been documented in the context of appropriate training and support for task-shifted personnel.16,17
Many developing countries have few options other than task-shifting for
the rapid scale-up of HIV care and treatment programmes.3,6,9,13

Even in the context of conflicting data regarding the reliability of
task-shifting, nurses are an attractive target for task-shifting of ART
management, given their ubiquitous role in health systems and their
availability in most high HIV prevalence settings. In Botswana there is
approximately 1 doctor per 3 500 people,18
but they tend to work in large urban facilities, beyond the reach of
Botswana’s largely rural population. Indeed, many rural clinics
are currently staffed entirely by nurses. Compared with other countries
in southern Africa, Botswana’s nurse-to-patient ratio is
relatively high,18 and this robust cadre is well positioned to catalyse ART rollout in the country.10,18

In response to Botswana’s limited supply of doctors able to
provide HIV management, the Botswana Ministry of Health’s
nurse-prescriber training programme commenced in 2008, extending access
to an estimated 20 000 clients in rural Botswana.19
Nurses are trained to become nurse prescribers to provide routine ART
management for stable patients, including children, as defined by
standardised criteria.

We investigated the performance of this new cadre of providers of
paediatric ART, using charting documentation to compare the rate of
compliance with national HIV guidelines by doctors and certified nurse
prescribers in a single government-affiliated clinic in Botswana. The
nature of the pre-service training received by the nurse prescribers
reviewed is as follows:

Training components. Four
weeks of training on management of ART for stable paediatric patients,
including didactics and practicum; an additional month of clinical
mentorship attached to a licensed physician with paediatric HIV
experience.

We are not aware of any studies that compare this metric in
resource-limited settings, and this is the first published study from
Botswana that compares compliance with national HIV guidelines of
doctors and nurses in the management of HIV-infected children. We
hypothesised that there would be no difference in guideline compliance
between physicians and nurse prescribers.

MethodsStudy design

We compared the performance of nurse prescribers and doctors caring
for HIV-infected paediatric patients using chart documentation as the
metric of performance. The medical records of paediatric patients aged
1 - 16 years who had been seen at the Botswana-Baylor Children’s
Clinical Centre of Excellence (COE), a large and busy
government-affiliated clinic in Gaborone, Botswana, between 5 January
2009 and 31 March 2009 were retrospectively reviewed.

Sampling

Patient visits (‘encounters’) were selected by
stratified random sampling conducted via review of patient records for
January -
March 2009. From the patient visits to the COE during this period, we
identified encounters which met our inclusion/exclusion criteria below
– a total of 800 doctor-patient encounters and 776
nurse-prescriber-patient encounters. Based on the randomly ordered
patient identification numbers, we then numbered the encounters. Using
a random number table and by spinning a pencil, we randomly picked a
starting point between 1 and 800 for the doctor encounters and between
1 and 776 for the nurse prescriber encounters. With this random
starting point, our selection of encounters for review was every 7th
encounter down the list until 100 doctor encounters and 97 nurse
prescriber encounters had been selected for the study. These patient
encounters were then audited by one of the study authors (GM) for
successful documentation of eight separate clinically relevant
variables: (i) adherence – pill count performed and charted; (ii)
chief complaint – patient complaints documented and attended to
in the plan; if no chief complaint was given by the patient, this was
stated in the chart; (iii) social history – social history with any changes documented; (iv) disclosure – if full or partial disclosure was reviewed with the patient and/or caregiver; (v) physical examination – adequate physical examination of at least six body systems; (vi) laboratory tests ordering (LTO) – monitoring laboratory tests ordered correctly according to national ART guidelines; (vii) staging – WHO staging performed; and (viii) dosing – paediatric dosing performed according to national ART guidelines.

Inclusion/exclusion criteria

All encounters met the criteria for standard, routine paediatric ART
management, defined by the Botswana Ministry of Health as an otherwise
well-appearing child, aged 1 - 16 years, on first-line ART for at least
1 year with the following characteristics: (i) viral load undetectable (<400 copies/ml) for at least 6 months after full suppression (<400 copies/ml); (ii) CD4 cell count (≥25% for children aged <13 years; >150 cells/µl for children aged ≥13 years); (iii) weight and height for age within two Z-scores of 50th percentile; (iv) developmental milestones within normal limits; and (v)
on first-line ART regimen as defined by the Botswana National HIV/AIDS
Treatment Guidelines: (stavudine or zidovudine) + lamivudine +
(nevirapine or efavirenz).

On the basis of these criteria, encounters with any non-stable
patients or patients on second-line or salvage ART were excluded. Also
excluded were acute visits for ill children, ART initiation visits, and
visits dedicated to counselling support.

Data collection methods

Encounters for review were selected based on stratified random
sampling as described above. The COE’s electronic medical record
(EMR) was used to generate reports for each encounter that detailed the
successful documentation of completion of each of eight clinical
variables.

We estimated that doctors would accurately document 90% of the
charted items, which is consistent with approximate upper limits in the
literature.20 We
predetermined that a documentation difference of more than 5% between
doctors and nurses would be considered clinically significant. A
two-group chi-square test with 80% power to detect a difference between
an overall doctor documentation rate of 90% and an overall nursing
documentation rate of 85% would require a sample size in each group of
at least 686 documentation items for our primary outcome. Sample size
was calculated with nQuery Advisor® 6.02 (Statistical Solutions,
Saugus, Massachusetts, USA).

Data analysis

Data were entered into an Excel database (Microsoft 2003, Seattle,
Washington, USA) and analysed using Minitab-® 15 (State College,
Pennsylvania, USA). Quantitative data were analysed for the eight
clinical variables individually and for combined values. Mean
compliance scores were calculated for both nurse and doctor encounters.
The two-sample test for binomial proportions was used to calculate p-values; a p-value
of less than 0.05 was considered statistically significant for our
primary outcome. For our secondary outcomes (the eight individual
documentation items), a p-value of less than 0.00625 using Fisher’s exact test was considered statistically significant. This reduction from a p-value
of 0.05 was due to the number of categories under evaluation, in an
effort to minimise the chance of a type I error by applying the
Bonferroni principle.

Ethical approval

This study was approved by the Health Research and Development
Committee (HRDC), Ministry of Health, Botswana, and the Institutional
Review Board, Baylor College of Medicine, USA.

Descriptive data

Two of the 3 nurse prescribers and 1 of the 10 doctors were female.
The average number of years of working with the most recent Botswana
National Guidelines at this time for the doctors and nurse prescribers
was 17 months (95% confidence interval (CI) 10 - 24 months) and 3.7
months (95% CI 3.0 - 4.3 months), respectively.

Outcome data

Table I describes the percentage of appropriate documentation for
nurse prescribers and doctors. Overall, nurses and doctors correctly
documented 96.0% and 94.9% of the time, respectively. There was a trend
towards a higher proportion of social history documentation by the
nurse; however, using a p-value
cut-off of 0.00625 according to the Bonferroni multiple comparison
methods, this value of 0.024 was not a statistically significant
difference between the two groups. There was no significant difference
in any other documentation items included in the study.

Discussion

This study, comparing certified nurse prescribers and doctors, successfully demonstrates comparable performance. All documented p-values
above reflect the non-inferiority of nurse-provided services compared
with doctors. The observed trend towards better attention towards
children’s social situations by nurses could be important in
determining ART outcomes, given the association between complicated
social situations and unsuccessful HIV care.21

Although published commentaries have discussed issues relating to task-shifting in Botswana,10,19,22
we know of no studies that have compared the quality of services of
nurse and doctor providers in Botswana. Additionally, the literature
review uncovered no data from any country or region establishing the
non-inferiority of nurses compared with doctors specifically in
relation to paediatric ART management.

A strength of our study is its reflection of routine clinical
practice in a busy paediatric ART centre. However, it has some
limitations, in addition to its retrospective design. The relationship
between the metric we evaluated – compliance with national HIV
management guidelines – and good paediatric patient outcomes is
not currently reported in the literature and cannot be determined by
our study. The need for further studies in this area is clear,
including prospective non-inferiority studies of routine paediatric ART
practice by nurse prescribers powered to explore differences in patient
outcomes, as well as cost-effectiveness of nurse-directed models of
paediatric ART care for specific clinical outcomes.

Care should be taken in broadly generalising our study results. Our
setting in a paediatric-specialised centre in a large urban area is not
necessarily typical of most settings in southern Africa or other
resource-limited settings where paediatric ART care is delivered. The
training received by nurse prescribers in our setting may also not be
typical of other paediatric ART settings. The latter is important, as
southern African studies of task-shifted care suggest that the nature
of pre-service training substantially influences provider practice and
treatment outcomes in patient cohorts managed by non-doctors.16,17,23

The nurse prescribers in CIPRA-SA were experienced and well
trained, all having undergone an additional year of clinical training
in primary health care and specialised didactic and clinical training
in HIV management, including ART.16 However, where pre-service training is less comprehensive, results have been concerning.13,15,17
In Mozambique, a nationwide evaluation of non-doctor clinicians
managing patients on ART noted a high rate of ART management errors;
correct management of all main aspects of patient care included in the
evaluation (staging, co-trimoxazole, ART, opportunistic infections and
adverse drug reactions) was observed in only 10.6% of reviewed
encounters.17 These clinicians (known as technicos de medicina)
had all received 30 months of general pre-service training not
including HIV/AIDS content, but only 2 weeks of HIV-specific didactic
training, mostly emphasising ART, before beginning to manage ART.
Subsequent to this evaluation, Mozambique’s scope of practice and
training for non-doctor cadres in HIV management was revised.17

Conclusions

In southern Africa, there is an urgent need to broaden current
doctor-directed models of HIV/AIDS care, particularly where children
are concerned. Our findings further support the continued investment in
programmes employing properly trained nurses in southern Africa to
provide quality care and ART services to HIV-infected children who are
stable on therapy. Task
shifting is a promising strategy to scale up and sustain adult and
paediatric ART more effectively, particularly where provider shortages
threaten ART rollout. Policies guiding ART services in southern Africa
should avoid restricting the delivery of crucial services to doctors,
especially where their numbers are limited, while ensuring that cadres
of health care workers to whom essential services are shifted are both
well trained and properly supported longitudinally.

Acknowledgements. The
authors thank the Centre’s patients and clinical team as well as
the Government of Botswana for its support of the Baylor College of
Medicine and Texas Children’s Hospital patient care, education,
and research activities in Botswana. They also acknowledge Mmapula
Sechele for her management of nursing activities at the Centre and Mary
A Gregurich for her assistance with some of the statistical
calculations.